Income Guidelines Family Size MINIMUM Family Size MINIMUM

OVER INCOME LEASE TO OWN PROGRAM Income Guidelines Family Size MINIMUM Family Size MINIMUM 1 $40,264 5 $62,122 2 $46,016 6 $66,723 3 $51,768 7 $71,325 4 $57,520 8 $75,926 Applicants MUST meet the above income guidelines THE ABSENTEE SHAWNEE HOUSING AUTHORITY ONLY ACCEPT COMPLETE APPLICATIONS INCOMPLETE APPLICATIONS WILL BE RETURNED OR FILED INACTIVE You must attach colored copies of the following documents with the application in order for the application to be processed: Driver s license or Stated ID for all household members over the age of 18. CDIB and /or Tribal Enrollment Cards (for ALL Native American household members) Social Security Cards (all household members) State Birth Certificates (all household members) Marriage License/Divorce Decree/Custody Decree (if applicable) Award Letters for Income (Social Security, SSI, Disability, Unemployment Benefits and Workman s Comp, etc ) if applicable Federal Tax Returns filed for the previous year and current year (if filed) Any other documentation requested by the Absentee Shawnee Housing Authority

ABSENTEE SHAWNEE HOUSING AUTHORITY P.O. Box 425 107 North Kimberly Shawnee, OK 74802-0425 Phone (405) 273-1050 Fax (405)275-0678 Over-Income Lease to Own Housing Application (use black or blue ink only) Applicant Information: First Name: Last Name: DOB: Middle Initial: Current Mailing Address: SSN: City: State: Zip: Do you own or rent? Monthly house payment? Rental History for the past *5 years (list most recent first) 1. Landlord Name: Length of occupancy? Address: City: State: 2. Landlord Name: Length of occupancy? Address: City: State: 3. Employer Name: Length of occupancy? Address: City: State: *List additional Landlord history on a separate sheet of paper Employment Information Current Employer: Start date: End date: If you have been with your current employer less than *3 years, list below previous employment. Employer: Start date: End date: Employer: Start date: End date: Employer: Start date: End date: *List any additional employment on a separate sheet of paper.

Co-applicant Information First Name: Last Name: DOB: Middle Initial: Current Mailing Address: SSN: City: State: Zip: Co-Application employment information: Employer: Hire date: Household Composition List all household members below: Name: Relation Sex Date of Birth Social Security # Self References List 3 personal references below. (must not be related) Name: Relation: How long have you known this person? Mailing Address: City: State: Zip: Phone# Name: Relation: How long have you known this person? Mailing Address: City: State: Zip: Phone# Name: Relation: How long have you known this person? Mailing Address: City: State: Zip: Phone# Emergency Contact Name: Phone# Relation: Acknowledgement I have answered every question and filled in all the requested information to the best of my ability. No fraudulent statements have been made or implied, and I have no objection to inquiries being made for the purpose of verification of statements made herein. I fully understand that false statements are subject to prosecution and/or rejection of my application. By signing this application, I understand I am subject to a home visit, credit report check, and criminal background to provide any additional information necessary to complete the application process. I understand that is my responsibility to update my application at least once a year, and must notify the Absentee Shawnee Housing Authority of any change of address, income or family composition and to answer any correspondence the Housing Authority send me and I understand that failure to do so will result in the application becoming inactive. Signature of Applicant: Signature of Co-applicant:

ABSENTEE SHAWNEE HOUSING AUTHORITY CONFLICT OF INTEREST POLICY PURPOSE: The purpose of this Policy is to help ASHA manage those situations where Conflicts of Interest arise within the Absentee Shawnee Housing Authority s housing programs to ensure fair and equitable treatment for all eligible participants of those programs. APPLICATION OF REQUIREMENTS The Conflict of Interest provisions apply to anyone who participates in any TDHE recipient s decision-making process or who gains inside information with regard to the TDHE assisted activities. Such individuals are, but are not necessarily limited to: housing staff, housing or Tribal Board Members, members of their immediate families, Council Members, members of their immediate families and such individual business associates. The requirements prohibit any such individuals from benefiting from their position personally, financially or through the receipt of special benefits other than payment of their salary and/or appropriate administrative expenses. This does not prevent housing staff, Board Members, their family members, Council Members, their family members, and/or business associates from receiving housing benefits for which they qualify, if not in violation of Tribal or State Laws. CONFLICT OF INTEREST A Conflict of Interest may occur when an employee of the Absentee Shawnee Housing Authority, a Member of the Absentee Shawnee Tribal Council/Board of Commissioners, or an immediate relative of an employee or Absentee Shawnee Tribal Council/Board of Commissioners is selected to receive assistance through any of the Absentee Shawnee Housing Authority Programs. DEFINITIONS: Immediate family: is defined as a parent, spouse, child, sister, brother, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, grandparents of the employee or his/her spouse, and grandchildren of the employee, or foster or step situations within these relationships.

ABSENTEE SHAWNEE HOUSING AUTHORITY PUBLIC DISCLOSURE STATEMENT A public disclosure regarding conflicts of interest must be made on individuals who apply for assistance from the ASHA and have immediate family ties (mother, father, husband, wife, daughter, son, brother, sister, mother-in-law, father-in-law, daughter in-law, son-in-law) to any employee or board member of the ASHA or elected Tribal Official. To ensure that all applicants are treated fairly, a public disclosure will be made before you are permitted to participate in the program. Do you have an immediate family tie to any of the above-mentioned individuals? Yes No If, yes please list their names and their relationship to you. Applicant s Signature: Spouse s Signature (if applicable): OFFICE USE ONLY The above has applied and has been determined eligible for services: The nature and basis of the assistance to be provided as follows: ASHA Representative Signature:

AUTHORIZATION For Release of Information CONSENT: I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to Absentee Shawnee Housing Authority any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under the Indian Housing program. I understand and agree that this authorization or the information obtained with its use given to administer and enforce program rules and policies. INFORMATION COVERED: I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquiries that may be requested include but are not limited to: Identity and Marital Status Employment, Income, and Assets Residences and Rental Activity Medical or Child Care Allowances Credit and Criminal Activity I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program. GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individuals that may be asked to release the above information (depending on program requirements) include, but are not limited to: Previous Landlords (including Past and Present Employers Veterans Administration Public Housing Agencies) Welfare Agencies Retirement Systems Courts and Post Offices State Unemployment Agencies Banks and other Financial Institutions Schools and Colleges Social Security Administration Credit providers and Credit Bureaus Law Enforcement Agencies Medical and Child Care Providers Utility Companies Support and Alimony Providers COMPUTER MATCHING NOTICE AND CONSENT: I understand and agree that the Housing Authority may conduct computer matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. The Housing Authority may in the course of its duties exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies. CONDITIONS: I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in affect for a year and one month from the date signed. SIGNATURES PRINTED/TYPED NAME Applicant: Spouse: Adult Member: Adult Member: Adult Member: WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department of Agency of the U.S. as to any matter within its jurisdiction.

ATTN: FOR HEAD OF HOUSEHOLD S SIGNATURE ONLY, PLEASE REQUEST ADDITIONAL FORMS FOR ALL OTHER HOUSEHOLD MEMBERS AT OFFICE DECLARATION OF SECTION 214 STATUS Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance, must be lawfully within the United States. Please read the Declaration statement carefully and sign. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing. I, certify, under penalty of perjury i, that to the best of my knowledge, I am lawfully within the United States because (Please check appropriate box): I am a citizen by birth, a naturalized citizen or a national of the United States. I have eligible immigration status and I am 62 years of age or older. Attach proof of age. ii I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS document(s) evidencing eligible immigration status and signed verification consent form. Immigration status under 101 (a)(15) or 101(a)(20) of the Immigration and Nationality Act (INA) iii Permanent residence under 249 of the INA iv Refugee, asylum or conditional entry status under 207, 208 or 203 of the INA v Parole status under 212 (d)(5) of the INA vi Threat to life or freedom under 243 (h) of the INA vii Amnesty under A of the INA viii (Signature) (Date) Check box on left if signature is of adult residing in the unit who is responsible for a child named on the statement above. HA: Enter INA/SAVE Primary Verification #:

i Warning: 18 U.S.C. 100t provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statements or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five years, or both. The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following categories: ii Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a documents providing evidence of proof of age. No further documentation of eligible immigration status is required. iii Immigrant status under 101(a)(15) or 101(a)(20) of the INA. A noncitizen lawfully admitted for permanent residence, as defined by 101(a)(20) of the immigration and nationality Act (INA), as an immigrant, as defined by 101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101 (a)(15), respectively [immigrant status]. This category includes a noncitizen admitted under 210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status. iv Permanent residence under 249 of the INA. A noncitizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under 249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249 ] v Refugee, asylum, or conditional entry status under 207,208 or 203 of the INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under 207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under 208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under 203(a)(7) of the INA (U.S.C. 1153(a)(7)) before April 1, 1980 because of persecution or fear of persecution on account of race, religion or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status]. vi Parole status under 212(d)(5) of the INA. A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under 212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status]. vii Threat to life or freedom under 243(h) of the INA. A noncitizen who is lawfully in the U.S. as a result of the Attorney General's withholding deportation under 243(h) of the INA (8 U.S.C. 1253(h)) [Threat to life or freedom]. viii Amnesty under 245A of the INA. A noncitizen who is lawfully admitted for temporary or permanent residence under 245A of the INA (8 U.S.C. 1255a) [Amnesty granted under INA 245A].